June 12, 2008
Spam, Fake Drugs and Health
The LATimes reports on the amount of money that spammers who sell fake prescription drugs, including viagra (I am sure that you have seen some of the ads in your e-mail) and how such spam will only increase. There is no discussion of the potential health issue - the focus is on the creativity of the spammers in creating their business model. Joseph Menn writes,
Cyber-crime pays. But selling counterfeit drugs apparently pays better. Some of the world's most prolific spammers used to tout products for a few pennies per million e-mails or con consumers into forking over credit card information. But these groups have found that the most profit and growth potential lies in actually shipping the fake Viagra and other products they're hawking, according to a study scheduled for release today by a top security researcher.
For consumers, the evolution means that what had been an annoyance and a drag on productivity will get worse. The new commercial operations use the same combination of cutting-edge technology and best practices, including customer service and supply-chain management, that have brought riches to Amazon.com Inc. and Dell Inc. . . . .
In the study, Peterson links the Storm system to a Russian drug maker called GlavMed, which uses factories in India and China to churn out knockoffs of Viagra and other popular drugs. GlavMed didn't respond to an interview request. Cyber-criminals have learned not only how to outwit the computer-security industry, but how to become self-sustaining businesses with substantial budgets for researching and developing new ways to deliver their merchandise. . . .
Security firm MessageLabs Inc. estimates that spam already comprises three-quarters of all e-mail. And an estimated 1 in 6 Internet-connected personal computers has been infected by programs that turn them into zombie armies of spam-senders.
Organized crime is exploiting software flaws and human curiosity to increase those numbers. For example, Storm, which emerged last year, uses a wide range of tricks to get users to download it. Instead of including suspicious-looking attachments, Storm sends e-mail with links to fake holiday cards and YouTube videos. When visited, those websites look for security holes in the computer user's Web browser and other programs. If they don't find those holes, they ask the user to download a purported video player or other software that infects his or her machine with the Trojan horse. To make the e-mails more enticing, Storm uses headings related to current events, such as the winter storm in Europe that inspired researchers to give the enterprise its name. . . .
About 80% of that spam now touts drugs from such websites as MyCanadianPharmacy.com, which Peterson estimates takes in $150 million each year. Most of those who place orders will get pills from Mumbai, India, or Shanghai that contain 100% to 110% of the advertised dose of the active ingredient. Exactly who is in charge of Storm remains a mystery. The few arrests and limited improvements in anti-virus software might have taught the remaining practitioners whom and what to avoid.
Just like the overuse of antibiotics can produce more resistant strains of human viruses, Peterson said, "We've generated these super-gangs in Eastern Europe that have moved way outside the jurisdiction of any law enforcement. They have created a criminal ecosystem that completely isolates them from the security community."
U.S. Life Expectancy at 78 - We're #30!
News organizations report on the rise in life expectancy in the United States - which now stands above 78 years. This is great news. The not-so-great news is that the United States placed 30th in overall life expectancy. The New York Times reports,
For the first time, U.S. life expectancy has surpassed 78 years, the government reported Wednesday. The increase is due mainly to falling mortality rates in almost all the leading causes of death, federal health officials said. The average life expectancy for babies born in 2006 was about four months greater than for children born in 2005. However, the United States continues to lag behind about 30 other countries in estimated life span, according to World Health Organization data.
Japan is No. 1 on the list, with a life expectancy of 83 for children born in 2006. Switzerland and Australia were also near the top of the list. "The international comparisons are not that appealing, but we may be in the process of catching up," said Samuel Preston, a University of Pennsylvania demographer. He is co-chair of a National Research Council panel looking at why America's life expectancy is lower than other nations'.
The new U.S. data, released Wednesday, come from the National Center for Health Statistics. It's a preliminary report of 2006 numbers, based on data from more than 95 percent of the death certificates collected that year. Life expectancy is the period a child born in 2006 is expected to live, assuming the mortality trends observed in that year stay constant.
The 2006 increase is due mainly to falling mortality rates for nine of the 15 leading causes of death, including heart disease, cancer, accidents and diabetes. "I think the most surprising thing is that we had declines in just about every major cause of death," said Robert Anderson, who oversaw work on the report for the health statistics center. . . .
Life expectancy was up for both men and women, and whites and blacks. Although the gaps are closing, white women continue to have the highest life expectancy (81 years), followed by black women (about 77 years), white men (76) and black men (70). Health statisticians said they don't have reliable data to calculate Hispanic life expectancy, but they hope to by next year.
Increases in female smoking are a major reason that men's life expectancy is catching up with the women's, Preston said. Improvements in the care of heart disease -- a major health problem for black Americans -- helps explain an improving racial gap, he said.
About 2.4 million Americans died in 2006, according to the report.
June 10, 2008
LA Hospital Settles Patient Dumping Suit
The L.A. Times reported recently that Hollywood Presbyterian Medical Center has agreed to a settlement of civil and criminal charges arising from allegations concerning patient dumping.
Hollywood Presbyterian Medical Center on Friday settled allegations that it left a paraplegic man crawling around downtown Los Angeles' skid row in a hospital gown and with a colostomy bag by agreeing to pay $1 million and be monitored by a former U.S. attorney for up to five years. The resolution of the lawsuit marks the biggest settlement so far in the Los Angeles city attorney's efforts to crack down on hospitals and other institutions that "dump" patients on skid row. Kaiser Permanente agreed to a smaller settlement last year, and the city attorney's office said it is investigating several other hospitals and medical offices suspected of dumping.
"This is another important step in our campaign to put an end, once and for all, to this horrendous and unconscionable practice in our city," said City Atty. Rocky Delgadillo. "Besides ensuring that this hospital will never again engage in this practice, this settlement will also bring programs that will help address the lack of medical care for homeless people in the Hollywood area."
As part of the settlement, Hollywood Presbyterian agreed to adopt new discharge rules and enhance services for homeless patients. The $1 million will go to nonprofit groups that aid the indigent and homeless patients in the Hollywood area and other parts of the city.
The case involving paraplegic Gabino Olvera, 54, came to symbolize the problem of dumping patients on skid row, an area that for decades has been plagued by homelessness and drug-related problems. Olvera, wearing a soiled hospital gown and a broken colostomy bag, was found in February 2007 crawling in a gutter downtown. Witnesses said they saw a Hollywood Presbyterian van leave the man on the street. They said they shouted at the female driver of the van, "Where's his wheelchair? Where's his walker?" . . . .
A city law that is to take effect in July will make it a misdemeanor to take a patient to a location other than his or her residence without written consent. The crime will be punishable by a $1,000 fine and up to three years corporate probation. . . .
As part of the settlement, Hollywood Presbyterian agreed to a series of requirements aimed at preventing future patient dumping and allowed Lourdes Baird, a former U.S. attorney for Los Angeles and retired U.S. District Court judge, to oversee the hospital chain's compliance. Baird, who is already overseeing the Kaiser chain, will report to a Superior Court judge in L.A.
Baird is to monitor the hospital for five years, but the agreement states that if certain standards are met, monitoring can end after two years. The hospital will also pay a civil penalty of $10,000 and cover $50,000 in city attorney investigation costs. Under the new rules, physicians, nurses and social workers are required to assess and document homeless patients' mental status and refer them for cognitive and neurological exams when needed. . . .
Jeff Isaacs, chief of criminal prosecutions and enforcement for the city attorney, said his office still has a civil suit pending against Arcadia's Methodist Hospital, alleging patient dumping. Over the last two years, his office has opened investigations into more than 50 cases of alleged dumping. The latest allegation involved a hospital in Costa Mesa accused of dumping a patient on skid row earlier this year.
Firing the Patient
The New York Times has a piece today by Dr. Rahul K. Parikh who writes about dealing with a difficult relative of a patient and deciding to end his relationship with the patient because of it. His decision-making process is rather interesting as are the many comments attached to the article from other doctors and patients. I actually didn't think that the mother was that bad - perhaps because I had some rather picky clients. The comment thread was quite illluminating as doctors spoke up about their right to end relationships with difficult patients. Dr. Parikh writes,
It wasn’t the boy I had a problem with. It was his mother. We had met a few months earlier, when I gave her 14-year-old son a diagnosis of mild asthma. I didn’t mind her tough questions, but her tone of voice put me on edge. She seemed suspicious, almost angry. Still, in the end I decided she was just a smart, assertive parent, and I let it go.
This time, she was more confrontational. She complained she had been “forced” to bring in her son for a physical because his school needed a doctor’s clearance before he could play sports. What kind of racket did we doctors have with schools? Why did she have to bring in her son when she knew he was healthy? I was taking her money for doing this?
I bit my tongue and tried to tell her why I thought they belonged here. Yes, he was probably very healthy. But an annual checkup could help him learn to take charge of his own health as he grew up, and it would give me a chance to encourage healthy choices and to get a good sense his emotional health during these challenging years. Finally, I pointed out, he was due for a tetanus booster. She was unimpressed. “I don’t believe in preventive care,” she said. “I’ll treat him for tetanus if he needs it.”. . . .
I have had my share of difficult patients and parents. But putting up with this lady had taken more time than it was worth, and it interfered with my taking care of her son. I wasn’t sure I wanted to do it again. I considered my options. I could be stoic, do my job and keep the boy in my practice. I could call his mother and ask her to keep her opinions to herself so I could focus on her son, though my instincts told me that this wouldn’t stop her. Finally, I could decline to see her son, and therefore her, ever again. In other words, fire my patient.
The physician-patient compact basically states that a doctor will care for a patient in exchange for compensation and that the patient will heed the doctor’s advice. Patients who disagree with their physicians, or just dislike them, are free to go elsewhere.
By the same token, this mutual contract gives a doctor the right to dismiss a patient. The most obvious reasons are failing to pay or missing multiple appointments. Refusing to adhere to treatments can lead to dismissal. So can being abusive to the medical staff. Of course, we need to exercise this option sensibly. Doctors cannot fire a patient in dire straits like severe pain, bleeding or a life-threatening situation. And of course, we cannot refuse to see patients because of their race, age, sexual orientation and so on.
But could I fire a patient because I didn’t like his mother? Colleagues who had studied the ethics and legal issues told me that the answer wasn’t clear-cut. . . . I thought about our conversation on the tetanus booster, when the mother said she didn’t believe in preventive care. I’m a pediatrician — prevention is in my DNA. If I accepted her view, I’d be compromising my conscience and my professional ethics. I couldn’t do that.
I wrote a letter addressed to my patient’s mother and sent by certified mail. I kept it brief: “Sometimes, a patient or family and doctor aren’t compatible. ... Therefore, I will be dismissing you from my practice.” I went on to advise them how they could get a new pediatrician and told them that until they found a new doctor, I would continue to care for her child’s mild asthma. Two weeks later, I received notice that they had gotten it. . . .
June 9, 2008
Elizabeth Edwards to Advise Obama on Health Care Issues
This is a bit of a surprise. Democratic Presidential Nominee Barack Obama announced today that Elizabeth Edwards will be advising him on health care issues. TPM Election Central reports,
Obama's speech in Raleigh launching his economy tour is underway, and towards the end, during a discussion of health care, he drops a surprise aside that wasn't in the speech's prepared remarks:
"By the way, I'm going to be partnering with Elizabeth Edwards, we're going to be figuring all this out."
Ezra Klein takes on the question of why doctors may be over-prescribing drugs. He writes,
. . . . Doctors make money from prescribing treatments. If, as in England, they made money by not prescribing treatments (i.e, through capitation pay, where they're paid X amount per patient, rather than per treatment), they would prescribe more carefully. You could even set up those salaries such that doctors made approximately what they do now (so they don't rebel), but they kept more of it as profit if they didn't spend so much on treatments. Over time, that would radically slow the growth in health spending. So too would increasing the supply of doctors and increasing the responsibilities of nurse practitioners, both of which the doctor's guilds oppose.
But there's more than just guild greed at work. Methods of rationing, like capitation, are a hard sell to voters who want to believe they'll get not only every treatment they could plausibly benefit from, but quite a few they couldn't plausibly benefit from. In general, patients have a Samuel Gompers attitude towards medical treatment: They want more. Doctors don't make much money when they prescribe unnecessary antibiotics for colds. They do it because patients want antibiotics -- they feel better knowing something has been done. And doctors want them to feel better. . . . This isn't a guild protecting itself so much as human nature pointing in a possibly harmful, and definitely pricey, direction. Doctors take an oath to heal, they don't take an oath to cut health spending.
Additionally, doctors prescribe a lot of useless treatments because, in the aggregate, they don't know what works. It's a bit shocking and a bit scary to realize how little evidence we actually have on treatment effectiveness. Recent years, for instance, have cast a lot of doubt on both angioplasties and cardiac bypass surgery. Lumbar back surgeries are widely thought to be bunk in health policy circles, but lots of doctors still think they work (after all, it's surgery, it must work!). . . .
If you reworked all the incentives for doctors tomorrow, they wouldn't overprescribe as much, but they might not get any better at prescribing care that's actually of high quality. That sort of transformation requires a whole lot of evidence, which means funding a whole lot of comparative effectiveness research. Currently, that's not happening, and so a lot of the data comes from medical device manufacturers, pharmaceutical companies, and so forth. . . . If we spent a couple hundred million a year testing treatments, we'd make it back tenfold in cuts to total health spending.